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Miscellaneous - 357 CANDLESTICK ROAD 4/30/2018 (2)
April 4, 2015 TH ER90Q8IF0d06 f�U(DfE0O-0ARAGROUPm FORM OF NOTICE OF CASUALTY LOSS TO BUILDING UNDER MASS. GEN. LAWS, CH. 139, SEC. 3B Building Commissioner, or Inspector of Buildings c/o City or Town Hall 1600 Osgood Street North Andover, MA 01845 Board of Health or Board of Selectmen c/o City or Town Hall 1600 Osgood Street North Andover, MA 01845 Fire Department or Arson Squad c/o City or Town Hall 1600 Osgood Street North Andover, MA 01845 RE: Our File No.: P1592126 Insured: KENNETH R & PAMELA J CONNOLLY Address: 357 CANDLESTICK ROAD, NORTH ANDOVER, MA Policy No.: D0576097 Loss Date: 02/22/2015 Loss Type: Building or Other Structure Damage A claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause Mass. Gen. Laws, Ch. 143, Sec. 6 to be applicable. If any notice under Mass. Gen. Laws, Ch. 139, Sec. 3B is appropriate, please direct it to my attention and include a reference to the captioned insured, location, policy number, loss date and claim or file number. If no reply is received from your office within ten days, we will assume you have no liens of any type against this property, and the claim will be paid in our customary manner. Sincerely, William Lamb Claims - Property manager 1-800-688-1825 x1137 NORFOLK & DEDHAM MUTUAL FIRE INSURANCECO.we 222 Ames Street, P.O. Box 9109, Dedham, MA 02027-9109 DORCHESTER MUTUAL INSURANCE CO.Telephone: (800) 688-1825 FITCHBURG MUTUAL INSURANCE CO. Fax: (781) 329-1818 101.61 Mcg Thiscertifies that ......................:................... �............................................................... has permission to perform.................:.'!..,`......................................................... plumbing.in the buildings of......... , b N(`D at .....3.x..7... .....................................................•P.� c....L � o� North Andover, Mass. Fee .�-x.Q^'..... Lic. No. �39i)i.......... Mle........ ...................................................... PLUMBING INSPECTOR Check # Date .'••41. 1....1.1t. ...... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK i 164Q CITY a✓ '— MA DATE[ I PERMIT # 1 JOBSITE ADDRESS3S ks-A _� OWNER'S NAME POWNER ADDRESS % Cain s7�zX /e—b TEL 9i FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL © RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: ® REPLACEMENT: PLANS SUBMITTED: YES ® NO FIXTURES 'l FLOOR--' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE( DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM I DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM t DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER _ (I 1 ( __-.-- f ._ .__1 .-..___._ -----__.1 .-..�� I � -_1 1 FLOOR/AREADRAIN _I 1 1 .__._ 1 1 __.__..1 . 1 ! __— _ 1 INTERCEPTOR (INTERIOR KITCHEN SINK I _ --.__3 _ -A ._`I _-._j _.._.._I LAVATORY ROOF DRAIN I I I { i t I (I I SHOWER STALL i .__._ t ..__ 1 _------ _--J SERVICE / MOP SINK TOILET URINAL _._! _ ! __._ --_.J Wi SHING MACHINE CONNECTION-- W-4TER HEATER ALL TYPES,�-- WATER PIPING OTHER INSURANCE COVERAGE: have liability insurance its a current policy or substantial equivalent which meets the requirements of MGL Ch. 142. YES .'NO Q IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY - OTHER TYPE OF INDEMNITY D BOND El OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER —i AGENT IE -11 OF OWNER OR AGENT { hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the (Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S AME �J/F I LICENSE # i3SSS �T SIGNATURE IMP JPQ CORPORATIONd#[3�a #��LLC PARTNERSHIP Q COMPANY NAME,v ;ADDRESS ` S; CITY�� _I STATE ZIP TEL % FAX CELLS EMAIL 3 o El z N ❑ 1-- W M W W LL ap Date .!.d ... 4........1.. I. ................. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION v N A,-2— l L 0 Thiscertifies that .................................................... ............................................ ha's permission for mt llation.� ........ �.. ................................................................. in the buildings of ....... .... C;:P.c.►.NJA ... I .................................................................... at ........ . North Andover, Mass. Fee ZP .. . ....... Lic. No. 177456) ....... ....... M$ ................................................ GASINSPECTOR Check #V;. -7 9170 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY {�/vv�-_iv�aCr MA DATE / Zo/Y PERMIT # lT } JOBSITE ADDRESS S% t OWNER'S NAME OWNERADDRESS S'% t(�,lL_ JZS�_ _ TE 5�A1gy?lFAX� TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL CLEARLY NEW: ,_[�f RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES F-1 NO . APPLIANCES I FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER [-! - 2 .-1 . FIREPLACE=J- FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS�— MAKEUP AIR UNIT, _- OVEN POOL HEATER _ _—J L ROOM / SPACE HEATER ROOFTOP UNIT TEST UNIT HEATER UNViNTED ROOM HEATER I f WATER HEATER - OT —R L-1 L— 1 �^ INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES �L�71vu I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [Z' OTHER TYPE INDEMNITY ® BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME LICENSE #L3 "3rPI SIGNATURE MP [I MGF Ej JP ® JGF [] LPGI © CORPORATION Tf# 3 PARTNERSHIP ®#= LLC E]# COMPANY NAME:a./mac ADDRESSL CITY M_y r � STATE, zlp dTEL FAX CELL[ ]EMAIL 4)8- - fs3 72"- O z 0 H U � W � M Pro r� zEl O N� � W f- W OE d Z U w �* W 3 F- CODCl) w 19 C0 aP6, w Cl) d g as a a U ' a a c w x w I- LL O z 0 H U W UD C�7 u The Commonwealth of Massachusetts Department ofIndustrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leizibly Name (Business/Organization/Individual): �M, 4 d• I)C(66 1—i HGF Address: S ,— City/State/Zip:M � f kvl-- /Phone #:_7 2 E?(S-- (f -r i 3 Are you an employer? Check the appropriate box: 1. 1.5" 1 am a employer with _ 4. ❑ I am a general contractor and I Type of project (required): 6. ❑ New construction employees (full and/or part-time).* 2. El am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. �• FJ Remodeling ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 5. ❑ We are a corporation and its 9. Building addition [No workers' comp. insurance required.] officers have exercised their 10. ❑ Electrical repairs or additions 3. ❑ I am a homeowner doing all work right of exemption per MGL 11. ❑ Plumbing repairs or additions insurance required.] t employees. [No workers' I I 13.❑ Other comp. insurance required.] *Any applicant that checks box 91 must also fill out the section below showing their workers' compensation policy information. i Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: {i( d Policy # or Self -ins. Lic. #: () k 51—? L) (V _5:3 7:) . Expiration Date: a Job Site Address - ,_3 S;) C;OWe� S � City/State/Zip: �/� �'57 Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to theimposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA. for insurance coverage verification. I do hereby certify under the pains andpenalties of perjury that the information provided above is true and correct. Signature10 Date: /�� /. Phone #• 228L- — e36— a� Z Official use only. Do not write in this area, to be completed by city or town official. City or Town: PermitlLicense # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - Contact Person: Phone #: Information and. Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract ofhire,- express or implied, oral or written." An employeiis defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or Iocal licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter.152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone numbers) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not requireil to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permittlicense applications in any given year, need only submit one affidavit indicating current Policy information (ifnecessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: `1'he Commonwealth of Massachusetts Department of Indusuial Accidents Office of Investigations 600 Washington Street Boston} ikMA, 42111 Tei. # 617-727-4900 ext 406 or 1-877AASSAFB Revised 5-26-05 Fax # 61.7-727-7749 www.mass,govfdma Division of Professional Licensure: License Search r M The Official Website of the Office of Consumer Affairs and Business Regulation (OCABR) Division of Professional Licensure Mass.Gov Home State Agencies A -Z Topics Mass.Gov ONLINE SERVICES , Check License Locate a Licensed Professional Online Address Change Contact the Agency More... REFERENCES & RELATED INFO Disclaimer Regarding Website License Searches Enforcement Process Glossary Glossary of License Status Codes More... Home > Division of Professional Licensure Check A Professional License By the Division of Professional Licensure i NEW SEARCH Pagel of 1 LICENSING BOARD Sheet Metal Workers Plumbers £t Gasfitters) Plumbers Et Gasfitters Plumbers ft Gasfitters Plumbers Et Gasfitters TYPE Master/unrestricted Journeyman Plumber Master Plumber Plumbing Corporation Apprentice Plumber LIC. # i 13848 25002 LICENSEE'S NAME I MARK B MAGNIFICO MARK B MAGNIFICO CITY/STATE MIDDLETON, MA MIDDLETON, MA MIDDLETON, MA MIDDLETON, MAS MIDDLETON, MAI STATUS Current Current Current Current Expired 13559 MARK B MAGNIFICO MARK MAGNIFICO 3266 20301 MARK B MAGNIFICO I The page above has been generated by the Division of Professional Licensure web server on Thursday, September 12, 2013 at 8:59:28 AM. © 2007-2011 Commonwealth of Massachusetts Site Policies Contact Us 7 / 0 Date..(.`.'�5.. ��• HO,tTp TOWN OF NORTH ANDOVER 10 n PERMIT FOR GAS INSTALLATION This certifies that . . w, /: has permission for gas installation .. f.Gd ..... //I f. in the buildings of ... 4�< --f k &.7 .A/we ............... at .,.?� .%... / + /J,,, Ilf ;!%: / ' ... , 1'Vorth Andover, Massa FeeAIU} Lic. No./3S}_ /s � G/ASINSPECTOR Check # �� !' d MASSACHUSETTS UNIFORM APPLICATIINOR PERMIT TO DO GASFITTING Mass. Dat26. 20 Permit # Building Location '7 ! Owner's Name * . e Type of Occupancy V kXVNew ❑ Renovation ❑ Replacement ❑ Plans Submitted: Yes ❑ No ❑ G M Installing Company Name /Y)jA GAB F>' cc) Address Check one: Certificate /74-^- aigte(jP,Corporation Business Telephone i736 - 2/y 3 ❑ Partnership Name of Licensed Plumber or Gasfitter /1&,/, e46 • ❑ Finn/Co. INSURANCE COVERAGE: I have a current liability ' urance policy or its substantial equivalent which meets the requirements of MGL Ch. 142 Yes No ❑ If you have checked yes, please indite the type of coverage by checking the appropriate box. A liability insurance policy 0 Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the MGL, and that my signature on this permit application waives this requirement. Signature of Owner or Owner's Agent Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. By Tof Licens Title Plumber e: Master Sig�eatur of Licensed Plumber/Gasfitter City/Town ❑ Gasfitter ❑ 7oumeyman License Number /�SS APPROVED (OFFICE USE ONLY) PLEASE COMPLETE REVERSE SIDE --* xw w W rn a U p O CU rn F P4 d o x �" z o W z H�>t 4 W Q d x ¢ ¢ F" C7 w F- d¢¢ cn z ~a E¢ w O aOa w a f' `F. W aG R O O w p w E~ O t7 w 3 A 0 a U a> a !~ A O SUB -BASEMENT BASEMENT FIRST (1ST) FLOOR SECOND 2ND) FLOOR THIRD (3RD) FLOOR FOURTH (4TH) FLOOR FIFTH (5TH) FLOOR SIXTH (6TH) FLOOR SEVENTH (7TH) FLOOR EIGHTH (8TH) FLOOR M Installing Company Name /Y)jA GAB F>' cc) Address Check one: Certificate /74-^- aigte(jP,Corporation Business Telephone i736 - 2/y 3 ❑ Partnership Name of Licensed Plumber or Gasfitter /1&,/, e46 • ❑ Finn/Co. INSURANCE COVERAGE: I have a current liability ' urance policy or its substantial equivalent which meets the requirements of MGL Ch. 142 Yes No ❑ If you have checked yes, please indite the type of coverage by checking the appropriate box. A liability insurance policy 0 Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the MGL, and that my signature on this permit application waives this requirement. Signature of Owner or Owner's Agent Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. By Tof Licens Title Plumber e: Master Sig�eatur of Licensed Plumber/Gasfitter City/Town ❑ Gasfitter ❑ 7oumeyman License Number /�SS APPROVED (OFFICE USE ONLY) PLEASE COMPLETE REVERSE SIDE --* The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 U1V www massgovJdia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: . Phone #: Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. * ❑Remodeling ship and have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.E] Electrical repairs or additions 3. ❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. A t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the subcontractors and their workers' comp. policy information. lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company N Policy # or Self -ins. Lic. M. Expiration Date: Job Site Address: City/State/Zip: Attach a -copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct 0 Signature: Date: Phone #• ` Oficial use only. Do not write in this area, to be completed by city or town ofciat City or Town: Permit/License #. Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone 0 MAGNIFICO BROTHERS PLUMBING HEATING & GASFITTING 31 FOREST ST. MIDDLETON MA 01949 (978)-836-2193(978)-265-6689 Proposal for work to be performed at 357 CANDLESTICK, N ANDOVER SEND TO: INVOICE #: N/A INVOICE DATE: N/A PROPOSAL DATE: 06/24/11 EARTHWORKS ATTN: DAN GILL SERVICE DESCRIPTION #MEN @_HRS LABOR and MATE- RIAL COST MAGNIFICO BROTHERS PROPOSES TO: FLAT $2,800.00 RUN NEW 1 " METER THROUGH BASEMENT TO UNDERGROUND PIP- ING TO JACUZZI HEATER. TOTAL LABoRAivD MATER%AL. COST "$2,800.00 ' THIS QUOTE IS VALID FOR 21 DAYS. Total Quoted(LABOR + MATERIALS): �800.00 THANK YOU! INVOICE #: TBD PLEASE CONTACT MARK AT 97&836-2193 IF YOU HAVE ANY QUESTIONS, OR TO SET UP SCHEDULING AND CONFIRM PAYMENT PLAN. THANK YOU FOR THE OPPORTUNITY TO QUOTE ON YOUR PROJECT. ** Payment is due and payable by date above. A late fee of $30/month will be applied after that date. Any returned payments will be charged an additional $30 service charge. All material is guaranteed to be as specified. All work to be completed in a professional manner according to standard practices. 1 0 1 64 04. Date.. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ........1.. 1 .......... ................................... has permission to perform ...... ...... ................ wiring in the building of ........ ...................... ..... yi ....... I .......... ? .......... at ......z...... ...... ZXN�rt;h Andover., Mass. Fee.... ?..K...... Lic. No...............Z, Zz ';Yw IiBC ICALINSPSM_ft Check# t Common -wealth of Massachusetts official use Onl Y .n Department of Fire Services Pemut No. BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/07] �4PPLICAilGN FOR PERMIT TO PERFORM ELE�+o- ave blank RICAL qpD All work to be performed in accordance with the Massachusetts Electrical Code (MEC) 527 CMR 12.00 WORK ®RK (PLEASE PRINTININK OR TYPE ALL INFO City or -Town of: NORTH ANDOVER Date: By this application the undersi ed To .the Inspector of Wires: gn gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) ��'7 �� Owner or Tenant Al ...,. t � � /' �I%- Owner's � -ale- � Owner's Address Telephone No. Is this permit in conjunction with a building permit? .yes /'-b4_ �V� No E] (Check Appropriate Bog) Purpose of Building Existing Service Amps / _VolUtility Authorization No. ts d Overhea❑ Undgrd ❑ No, of Meters New Service Amps _ / _Volts Number of Feeders and .APm acity Overhead Undgrd No. of Meters III Estimated Value of Electrical Work:Attach additional detail if desired, or as required by the Inspector of Wires. Work to Start �S3o-G0 (When required by municipal policy.) C ' Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE CO RAGE: •Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee.provides proof of liability insurance including `°completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER - I certify p ❑.(Specify:) 1� ,under the gins and penalties ofperjury, that the in on this application is true and complete. FIRM NAME: Licensee: 0.g�� Si LIC. NO.: ) Signature LIC. NO. - Address: enter exem t nz the lice a um er line-) X826 Bus. Tel. No. *Per M.G.L 114 � c� 6, Alt: Tel. NO.: 61, security work requires Department of Public Safety,,S" License: OWNER'S INSURANCE W �� �� Lic. No, r WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $S Location and Nature of Proposed Electrical Work: ( - No, of Recessed Luminaires res Com letion of the Ins followin table may be waived by the ector of R No. of Ceil: Susp. (Paddle) Fans No. of No, of Luminaire Outlets No. of Hot Tubs Tota! Transformers KVA No of Luminaires Swimming Pool Above ❑ In- Generators 1KVA o. o mergency -d• No. of Receptacle Outlets nd• ig g ❑ Batter Units No. of Oil Burgers No, of Switches FIRE A - S No.' of hones No. of Gas Burners No..of Detection and No, of Ranges No. of Air Cond. Total I 'bath ' Devices . No. of Waste Disposers ns Heat Pump Number T �' No. of Alerting Devices 1 11 Totals: """•"�' ......••• ns No. of Self -Contained No, of Dishwashers Space/Area Heating K W Detection/Alerting Devices Local ❑ Municipal No. of Dryers ry Heating Appliances KWSecurity Connection El Other Systems:* No. of Water KW Heaters W No. of No. of Devices or E uivalenf No. Hydromassage Bathtubs Si s Ballasts. Data Wiring: No. of Devices or E uivalent No. of Motors Total HP Telecommunications Wiring: OTHER: No. of Devices or Equivalent III Estimated Value of Electrical Work:Attach additional detail if desired, or as required by the Inspector of Wires. Work to Start �S3o-G0 (When required by municipal policy.) C ' Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE CO RAGE: •Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee.provides proof of liability insurance including `°completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER - I certify p ❑.(Specify:) 1� ,under the gins and penalties ofperjury, that the in on this application is true and complete. FIRM NAME: Licensee: 0.g�� Si LIC. NO.: ) Signature LIC. NO. - Address: enter exem t nz the lice a um er line-) X826 Bus. Tel. No. *Per M.G.L 114 � c� 6, Alt: Tel. NO.: 61, security work requires Department of Public Safety,,S" License: OWNER'S INSURANCE W �� �� Lic. No, r WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $S ELECTRICAL PERMIT NO. INSPECTION REPORT: v - ELECTRICAL MSPECTOR - DOUG SMALL o - w 1. ROUGH INSPEC------------- TION: Passed — [ ] Failed — [ ] Re- inspection requirecT ($50.00) Inspectors' comments: (Inspectors' Signature - no initials) Date Z. FINAL INS CTION: Passed — Failed — [ ] Re -inspection required ($50.00) sc- [ ] Inspecto ' omments: i (Inspectors' Si ature - no initials) Date 3. UNDER GRO INSPECTION: Passed — [ Failed — [ ] Re -inspection required ($50.00) Inspectors' comments: (Inspectors' Signature - no initials) Date _ Z� 4. INSPECTION — SERVICE: - DATE CALLED NATIONAL GRID: NAME: Passed — [ ] Failed — [ ] Re -inspection required ($50.00) Inspectors' comments: (Inspectors' Signature -.no initials) Date V NSPECTION - OTHER: sed—[ ] Failed — [ ] Re -inspection required ($50.00)[]pectors' comments: (Inspectors' Signature - no initials) Date DOOR TAGS ARE TO BE FILLED OUT AND LEFT ON SITE IF THE .AREA TO BE INSPECTED IS NOT ACCESSIBLE AND A RE_INSPECTiON OF $50.00 IS TO BE CHARGETj. I 'l ";� &\_ The Commonwealth of Massachusetts t Department of Industrial Accidents Office ofInvestigations 600 Washington Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers APPHeant.Information Please Print IJe ibI Name (Business/Organization/Individual): �F Address:� City/State/Zip: 11A 0( &L/ Phone #:_ A re you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* 2 I am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet, t ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] 3. ❑ I am a homeowner doing officers have exercised their right all work of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No t=lorkers' comp. insurance required] Type of project (required):' 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other t compensation policy "`.'uY applicant that checks box :ul mrst also fit Cut the section below showin g� n I _ I Homeo%mers who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp, policy information. I am an employer that is providing workers' compensation i information. nsurance for my employees Below is the policy and job site Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: }; City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Q. Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the . s and penalties of perjury that the information provided above is true and correct Signature: Date.: Phone #: Efte only. Do not write ite in this area, to be completed by city or town official n• Permit/License # hority (circle one):Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. PIumbing Inspector ------------------ son: Phone #: Date ..:. % > .......,........ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that I �'�� ........................................................................................... has permission to perform ..6. f\-`v...vf..1.�. ........................... wiring in the building of v�U L `� 1 ............................................. at .....3 ..... ..L LTi .�� ,North Andover, Mass. ........... ..... .......... Fee ....... �..... 1 Lic. No..'. e. 3.G.d ....................... .LECTRICALINSPECTOR Check # 939rl j Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. �/ 3 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev, 1/07] APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE P&WTININK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) 1� % t! c� . n(� ` Owner or Tenant Owner's Address,�,� fi Is this permit in conjunction with a building permit? Purpose of Building Existing Service�XAmps X22/ olts New Service Amps / Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: a-- -C- No. of Recessed Luminaires No. of Luminaire Outlets No. of Luminaires No. of Receptacle Outlets No. of Switches No. of Ranges No. of Waste Disposers --------------- No. of Dishwashers No. of Dryers Heaters KW No. Hydromassage Bathtubs Telephone No. Yes ❑ No (Check Appropriate Box) Utility Authorization No. Overhead ❑ Undgrd)2� No, of Meters Overhead ❑ Undgrd ❑ No, of Meters the No. of Ceil.-Susp. (Paddle) Fans INo. of Hot Tubs Swimming Pool Abd e ❑ No. of Oil Burners No. of Gas Burners No. of Air Cond. , a SVO R 0 m be waived b the Inspector of Wires. of nsformersTn7A — Total� erators KVA o mergency ig te UnitsL� jNo. lg ALADI�IS �?a. of'..ones of Detection and Initiatin Devices of Alerting Devices Space/Area Heating KW Local ❑ Municipal Connectioi Heating Appliances KW Security Systems:* No. ofo. No. of Devices or Si s Ballasts of Data Wiring: asts . No. of Devices or No. of Motors Total HP Telecommunications No. of Devices ar ❑ Other Attach additional detail if desired, or as required by the Inspector of Wires. �tU Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start '5—/3—/CD bWectioris to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ;g BOND ❑ OTHER ❑.(Specify:) WZi)FW I certify, under the pains andpenalties ofperjury, that the information on this application is true and complete - FIRM NAME: J �Ir Com: L LIC. NO.: ilk 3 Licensee: „'`�� S Signature (If applicable, enter "exempt " in the license number line) LIC. NO.: 5 Q Address: Bus. Tel. No.: 1? -7- *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: �� L cl. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent Owner/Agent Signature Telephone No. PERMIT FEE: $ V a The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations kip 600 Washington Street Boston, MA 02111 www mass govldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lea><bIy Name (Business/Organization/Individual):_� ` �� Address: v City/State/Zip:_ "b�c -,, 4. /i%,� l g�2 Phone #: c! Are you an employer? Check the appropriate box: 1AI am a employer with 3 4. ❑ 1 am a general contractor and I employees (full and/or part-time).* 2. ❑ I have hired the sub -contractors am a sole proprietor or partner- listed on the attached sheet I ship and have no employees These sub -contractors have working for me in any capacity. [No workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its required.] 3. [1.1 am a homeowner doing all work officers have exercised their right of exemption per MGL myself. [No workers' comp. C. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] 5-- 9S- 7 - 1,_� /6 Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10 Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.0 Roof repairs 13. ❑ Other - -- - ------_.., .. omeav- ui Uu� u:c �uOn ne:^R' worker' comp`:.sation policy :nfor":,�tron. t Honer who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company N Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Si atare: Date: Phone #: Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: At� Q Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners,. are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permittlicense applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-72.7-4900 ext 406 or 1-877-NIASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass_gov/dia Date v/ Of Np DTH ' TOWN OF \ORTH ADOVER A PERMIT FOR GASSTALLATION � �SSACMUSE� / This certifies that .����/.-c�P-I� j has permission for, gas installation .... .. ....... . in the buildings of , Qom.. ��?�?�. �: �'j.. ............... . at .�,� ...G�(��'?�1. S�? �/G .:. , North Andover, Mass. Fee.. 3 f- Lic. No... . ...................... . GASINSPECTOR Check # 7247 Y MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FITTING (Type or print) Date j O NORTH ANDOVER, MASSACHUSETTS Building Locations -352 Permit # Kew e,�lyy-1Amount $ Owner's Name New Renovation ❑ Replacement ❑ Plans Submitted ❑ GAN. IIJ � w � N SID� h cD w a W o H o w Q y" a z y z a o o H W L Gw w z U w x w o - x a A x o 0 Z x o x 3 0 a° ° w SUB -BASEMENT BASEM ENT IST. FLO O R 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR 8TH. FLOOR (Print or type Check Name_ ��l! (s /L` Ucl jZ�/✓C� P--4-( one: Certificate Installing Company Corp. ss Address �G�S ��: LbNDQNt%Za✓L`/ �i/� 0303 ❑ Partner. Business Telephone g T ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter D(Jc/ (-H i i�(JC.I fZ�J N� INSURANCE COVERAGE Ch kJone. I have a current liability Insurance policy or it's substantial equivalent. Yes No ❑ If you have checked des, please indicate the type coverage by checking the appropriate box.."'. Liability insurance policy Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver: I am aware that the.licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent _, _._. _ . ... u ,,, i uav, ,u„iluLLu, kur mwreu) in aoove application are true and accurate to the best of my knowledge and that all plumbing work and insta ations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachus State Gas CoA and Cjrapter 142 of the General Laws. By: Title City/Town IAPPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter ❑ Plumber /( 7 y11 ❑ Gas Fitter License Number Master ❑ Journeyman -4 The Commonwealth of Massachusetts Department o f Industrial Accidents Office of Investigations 600 Washington Street Boston, AL4 02111 www.mass govldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Lf Phone #: 6�3 S2 4 '{%/ C -- Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.11 Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ Other t Flomeownem who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a tion new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub contiacto:s and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance formy employees. Below is the policy and job site information Insurance Company Name: Policy # or Self-ins..Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. i ao hereby c r .)J' under the p 'ns and penalties of perjury that the information provided Si ature: Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License 4 Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumb Inspector 6. Other is true and correct U Contact Person: Phone #: Are you an employer? Check the appropriate boa: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* 2. M11 am a have hired the sub -contractors sole proprietor or partner- listed on the attached sheet t ship and have no employees These sub -contractors have working for me in any capacity. [No workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its required.] 3. ❑ I am a homeowner doing all work officers have exercised their right of exemption per MGL myself. [No workers' comp, c. 152, § 1(4), and we have no insurance required] t employees. [No workers' comp. insurance required.] ' :Any applicant that cheery box 1 must also fill out the se rim beiev, sbowin* Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.11 Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ Other t Flomeownem who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a tion new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub contiacto:s and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance formy employees. Below is the policy and job site information Insurance Company Name: Policy # or Self-ins..Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. i ao hereby c r .)J' under the p 'ns and penalties of perjury that the information provided Si ature: Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License 4 Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumb Inspector 6. Other is true and correct U Contact Person: Phone #: +b , Information an d Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual., partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number. ,The Commonweal& of Massachusetts Department of Industrial Accidents Office of Investigations 60:0 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised. 5-26-05 Fax # 617-727-7749 vvwu,.mass._gov/dia. DffAA7UW 0FM lX5My B04RD0FFIRB1RLt'Vl7VllWRWl1(1MOV M7aVJZ* Pen dt No" OCCnPary & Rea Checked ..� APPUCATTONFOR PERMI'TO PERFORMELECTRIC,AI, WORK ALL WORK M BE PERFORMED IN ACCORDANCE WrM THE MASSACHUS. ELECTRICAL (PLEASE PR NT IN INK OR TYPE ALL OMRMATION) CODE, 527 CMB 12:0) Town of North Andover Data The undersigned applies for a permit to perforin the electrical Work described below. To the Inspector of Location (Street & Number) Car.� .X7' /�l Owner of Tenant ����„� Owner's Address;;'��; is this permit in conjunction with a building permit; Yes No Purpose of Building (mak ApPropriat° Box) Existing Service Amps=—Volb ONe� Utility Authorization No. New Service Amps f Undergtou� a No. of Meters ��� Voltz Overhead Uttderg Number of Feeders and Ampacitp C3 No. of Meter Location and Nature of Proposed Electrical Worts No. of Gsbdna Ontkb No of Hoi Tube I ra.of T /N%aAl�Cond. Totd No. of Disposals � No. d Hat TTotalTToldTon• FIRE No. of Z x= Toa Of DVI0cdQG and No. of Dfehwuhen Space Ara Heudeia KW Inida- KW NODwlca Na of Drymt ftofsmft dad Hati,y Devloee KW Oelxdonts000pa Dewe No. of Water Heuer KW sNo of No. ocd C� dm OUNr o_ of No. Hydro Mmsp Tube B TOWIiHl' HI l&*uftdmWpMofsNWI06CMM Ye BM f7 •r Wadcb&tEXbnpreRe+�rr�d �r mDd�' .RINI 0�'�5����a�fRIanrawaedait�heL'caer ;rdd�etrrp�sgeimon��� fire�iasrl�� (Please check one) Owner Apt Ra*EdM*dVdaaf M Lk=Na AtTel, Nn Telephone No.--z' o. FEE Date ........ .... /TOWN OF NORTH ANDOVER a PERMIT FOR PLUMBING SSACHUS This certifies that .... Q. . . a........ e -. . r, * ................... has permission to perform..,.:.� ................... .............. 04 plumbing in the buildings of . .,<. . . 7 . . . . . . . . . . . at 3 �44A Nor6/ Andover, Mass.. Fe/ .. ... ... -1.11 ....... e Lic. No. PLUM27PSPECTOR Check # MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Location—l-�–'l wners Name e z /L _ 1114 I . _ DD 49 LW FIXTURES Date Z. Permit # Amount J/, 1'7 (Print or type) / Check one: Certificate Installing Company Name Corp. Address 0 Partner. 2— Business Prelephohe C Ft/Co. Name of Licensed Plumber: Insurance Coverage: Indicate tM, type of insu a cover ge by0hecking the appropriate box: Liability insurance policy'Other type of indemnity 0 Bond 0 Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature IOwner I hereby certify that all of the details and information I have best of my knowledge and that all plumbingwork and ins ll compliance with all pertinent provisions of the Massa By: Signarg,e Signor j T Title Z> City/Town LICehnsem APPROVED (OFFICE USE ONLY 11 Agent 0 entered) in above application are true and accurate to the ?)erfonyied under -Pe Issued for this application will be in t o havter 142 of the Generali is . License MasterJourneyman o 6121 NORT►, 0 O A �,SSACHUS� TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that.:L':.=.................................................................................... has permission to perform 11---l-15. .............................................. wiring in the bui ding of .................. ................ ............. . ........................... .................................................... ......................... ,North Andover, Mass. G� .�ii. ELECrRICAL I SAO =TO Check # 116-1110 DEPAR IWOFRIBUCSUM permit Na BQARDOFF=PRCvzvn ivRBMAIIOAfSSl7aM,aio, = oL_ Occupanry s< Fees Checked APPuCATTONFOR PERMU7*0 PERFORM ELECTRICAL WORK Am WORK TO BE PERFORMED IN ACCORDANCE WrrH THE MASSACHUSM ELECTRICAL CODE, 517 CMB 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) jDat&� Town of North Andover The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) Owner or Tenant Owner's Address CJ To the Inspector of Wires: Is this permit in conjunction with a building permit Yes [a No (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service � Arnps....L.V olts OverheadUnderground No. of Meters New Serves Ampa� Volta Overhead Underground Q No. of Meters Number of Feeders and Ampacity A-) -1-6 /1 e,,4CC 7, -d -e/ Location and Nature of Proposed Electrical Work Na of Lighting Outho 5/ . Na of Hat Tube No. of Trwilorrowe Timid KVA Na of Ligbthy RMUM { 3wimndng Pool' Above Bebw aaeaaton KVA Na of Receptacle Oudete No. of Olt Buenas Na of Emerpm7 Lighting Battery Units Na of Switch Outim No. of ase Boeaas FIRE ALARM' No. of Zem. No. of Randa / No. of Air Cad. Toter Tote No. of De actim and No. of Dispoak Na d Heat Totd TOW Po Ton Kw liddaling Davkee No. of No. of Dishwahen Spero Area Heating KW / No. of SelfContsizwdd Defectionisoundws sa Load mici MwdcipalC3Other Na of Dryus Hoeft Devisee KW eu Coarcdan No. of Wain Heaters KW Na d No. of slim Bei1Me Na Hydra Mwaae Td o Na of Moron Told HP hUMMOMWPtroi 0109151ec}ilmiesdafMaeacfise6 15 11 1 mllsM IhmsttrrMv&p WCif =1Df Oft YM I w UYC4 El B ❑ On= 0 Wo&k)Sw,�. —L`. i�ec nDraeRec�r�d Srg;ndmd,rTzft 2ofMW fRtMNAMB do YM LJ NO ED )<youhateYEKphmkdm2eWci(wnVby 13gialinnDo E dVakzdE�bctt WWCk s Roigt list UZWNa .. LiamseNo c�ik//�' Budras'IirlNa -7,f1 9,?3 AlTdNa OWD,WSMAtANZWAMR;Iamavndatttlleiimwdmwt dieiaxmw%wpa*arhwwaovimtatmpwbyMrofta candLMG ardd�etrr�sgtratuernfiapear�appla�a firequimas (Please check one) Owner Age _ Telephone No, pgtmr• FEE -� Location s 7' ..3 No. % Date o �oRTM TOWN OF NORTH ANDOVER i • Certificate Occupancy + ; , of $ ,s34tMU`+ES Building/Frame Permit Fee $ _[_. Foundation Permit Fee $ Other Permit Fee $ TOTAL $ f7l�_0' F Check # 18571 `building Inspector , TOWN OF NORTH ANDOVER ' BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REP RENOVATF, OR DEMOLISH A ONE OR TWO FAMILY DWELLING . ..,. �+� r BUILDING PERMIT NUMBER: DATE ISSUED. SIGNATURE: Building Commissioner/I or of Buildings Date SECTION 1- SITE INFORMATION Address: ��% 1.1 MZ-,�L 1.2 AssessorsMap and Parcel Number: DL Map Number Parcel Number 1.3 Zoning Information: Zonin District Proposed Use 1.4 Property Dimensions: Lot Area Frortta ft 1.6 BUILDING SETBACKS ft Front Yard . Side Yard Rear Yard Required Provide Required Provided Recpimd Provided 1.7 water Supply M.G.L C.40. 34) t.5. Flood Zone lnfomution: Public - ❑ Private ❑ Zone Outside Flood Zone ❑ 1.8 sew erage Disposal System: Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT Mstoric IS CIC : 2S O 2.1 Owner of Record �.��„v � �� �.U,� a 1(� �3s"7 C.� ���2� �Q . i� �c�✓ems Name (Print) Address for-�S-e77rytce Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Lice// Construction Suuper�iso�r:/ /�-� Licensed Construction Supervisor: - Address Z `y r-�J Si re -- Telephone Not Applicable ❑ eS� 6,12-217S License Number 7 Expiration Date 3.2 Re stered Home Improvement Contractor < Not Applicable 11 Comp$ny Name Registration Number E irationDDate�� 0 6 Addres's �p 4 9UOW ��� � �� t n Telephone SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 Description of Proposed Work check all a ncable New Construction ❑ 1 Existing Building ❑ 1 Repair(s) ❑ 1 Alterations(s) Addition ❑ Accessory Bldg. ❑I Demolition 11I Other ❑ Specify Brief Description of Proposed Work: � r(k4�x_ I SECTION 6 - ESTIMATED CONSTRUCTION COSTS I Item Estimated Cost (Dollar) to be Completed by permit applicant 0MCIAL USE ONLY ' 1. Building (a) Building Permit Fee Multiplier .2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) x (b) 4 Mechanical (HVAC)�- 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner/Authorized Agent of subject property Hereby authorize �jUG�H /* ll-aGL6a to act on My behalf, in all matters relative to work authorized by this building permit application. I Signature of Owner Date I Q CT1nN 7h nWN1VR/A11THnR17 n AGENT MCLARATInN 1, as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Name Si ature of Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR THVIBERS 1ST2 ND 3 RD SPAN DIMENSIONS OF SII.,LS IIIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS r SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND t IS BUILDING CONNECTED TO NATURAL GAS LINE 0 t f� .\ - -- -�------.. _ ..------ Deportment of Ind>rstrtal Accidents Office of Inves4adons 600 Washington Strut Boston, MA 02111 www.massaov/dig Workers' Compensation Insurance Affidavit: Builders/Contractors/Electridana/Plumbers Name(Hu*ms/orBurizatimindividua�t)��- Address: City/State/Zip: hydfZ41--f- X% Phone #• Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am it employer with 4. ❑ I am a general contractor and I yMbyees (&H and/or part-time).' have hired the sub-contractmra 6• [:]New con:tr:ection 2. I am a sole proprietor or partua- listed on the attached sheet. ; 7. ❑ Remodeling ship and have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. worker' comp. insurantx. 9 ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10 ❑Electrical gas or additions required.] officers have exercised their nP 3. ❑ I am a bomeowner doing all work right of exeaiptim per MGL 11. ❑ Pfimbing npairs or additions myself. [No workers' Comp, c. 152, )1(4� and we have no 12.❑ Roof regain insurance required.) t employers. [No worker' 13..[] Otlba cow. insurance remuked-1 -qtly applWAM o Ga um s l lam goo nu om IDC s 00 MOW 9NOW64 ON& � O&M 9 �dn polk in� t Homeowners w'60 subn* flus affidavit tbsy ate &=a all watk gad t6m bite =to& waschn mint submit a nm at &Vit iadicaRing suck tContracMn OM cbmk brie baa most sttscbad M MWMaW dust sbows tits nine of tis =b 0onOWWM sad Owk wortas' MW PO&T infommilm I aur an emplayer AW tb prvvtdlrea rwders I cor ywwatloe Jesuneee for my eeeployees Below Is d w poliq amd job sus Jefonreatlern. Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State2ip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiref under Section 25A of MGL c. 152 can lead to the imposition of crmisal penalties of a fine up m $1,500.00 and/or one-year bWrisonmM as wen as chi pen allies in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a COPY of this statement may be forwarded to the Office of Investigations of the DIA far insurance coverage verification. I do thereby certifynet r thepales etrrdpeezk n ofperfury that the Info w"doe pmvl&d abom b sure and earrece , _ n / - kl,,4-,7- - ff,6 O okra! use only. Der red wrhe IN thk area, to be completed by co or town oA%Jed City or Town: Permit/I.ieeme 0 Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. Ckyrrowe Clerk 6. Other G 4. Electrical Inspector S. Plumbing Inspector Contact Person: Phone 0: Massachusetts General Laws chapter 152 requires all employers b provide workers' compensation for their employe. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." t An empWar is defined as "an individual, partnership, association, corporation uir other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall'not because of such employment be deemed >n be an employer•" MGL chapter 152,125C(6) also stain that "every state or local licensing agency ship withhold the issuance or renewal of a license or permit to operate a badness or to construct buildings in the commonwealth for nniy applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152,125C(7) stain "Neither the rmnonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of ccnnpliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants , Please fin out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone mmniber(s) along with their certificate(s) of insurance. Limited Liability Companies (LLCM or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required io carry worken' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be, advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sun to dga and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Depatfinew at the mmmber listed below. Self-insured companies should enter their self-insurance license Mizin on the appropriate line. City or Town Officials Please be sure that the affix avit is complete and printed lgpbly. The Deparhnent has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant Please be sure to fill in the permiVliconse number which will be used as a reference munber. In addition, an applicant that must submit multiple permit/limw applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit 110 has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid a vit is on file for future permits or licenses. A new affidavit most be filed out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required b complete this affidavit The Office of Investigations would hire to thank you in advance for your cooperation and should you have any questions, please do not hesitate to givens s cafi. - The Department's address, telephone and fax number: The Cammonweallth of Massachusetts Depament of Industrial Accidents. Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26.05 Fax # 617-727-7749 www.mm.gov/din 2q**ff*14 rt NT tf 1 I• 1 \ \ ♦ V REMODELINGNEW ENGLAND HOME MELROSE,General Contractore 35 PINE STREET, 662-5863 PROPOSAL SUBMI ADDRESS PHONE r R �; � �I PLAN JOBWAME AND LOCATION�; / / ,%' / / h JOBPHONE We hereby submit specifications &W estimates. subject to all Items and conditions as set forth bolovr. 1644 i II EMMM / ` N ISO / ! / LAW41 e 11tPrOP0111111! hereby to furnish fflaftrfa11 and labor —/am/ nime In accordance with above specifications. for the surn of: dollars (S Not- This Proposal May be wll&i*-w by us It not accepted within /` Autho days. 111119natu i ACC PU101: The above prim. specifications and conditions an satisfactory and are hereby accepted. You ars authorlted Io do the work ss spselfted. Payment will be Made d outlined above. Data, went t/ LAS 1" 41.410-0&0 •dill, •1' *J I � y C • 1 i MIA CCtitta: The above Pleas, specifications and conditions w U satisfactory and are hereby accepted. You are authorized to do the 819hature work as specified. PaQyn�•ntjwill be niedg •e outlined above. Oats - 7 ��/ f%% alpnNur• '(z�b Proposal v NEW ENGLAND HOME REMODELING ASSOCIATES Qananl Contractors 35 PINE STREET, MELROSE, MA 02176 662.5863 We hereby submit specifications end satimetss, subject to all Items and conditions as set forth below: PIANS r rT x/d OL Not- This Proposal may be wlthdio- by us If not accepted within Authorized days. Slpnstura„ ACC b: The &bow prices. specllioetlons and conditions are eatlafae cry and we hereby accepted. You we authorized to do the work as Specified. Payment will be made so oulNned ebow. oats dollars (f l 4 ��a1Nr�rirtt� �P; a■}�a��caa NEW ENGLAND HOME REMODELING ASSOCIATES General Contractor U 35 PINE STREET, MELROSE, MA 02176 662.5863 PROPOSAL SUB IT2TED L 'J DATE ADDRE ,j,:57-7 PNON A PLANS -r— 16�v C! J JOB NAME AND LOCATION ARC7&f-4v 1 _ JOSPHONE We hereby submit specifications and estimates, subject to all Items and conditions as est forth below: a Ail CtiC/� Alt 66 / !/ L ' J y/� r �Y�✓�� fy(/ St ilrOPOSE hereby to furnish material and labor — complete In accordance with above specillmions, for the sum of: dollars(f Notr This proposal may be withdrawn by us It not accepted within Authorized days. Blanstu + ACCtptta: The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payment will be made as, outlined above. Date . -=:/ZQf �rrt*tlrt�trl 11'7 ° ,�I•a a■�•a��•csa NEW ENGLAND HOME REMODELING ASSOCIATES General Contractors 35 PINE STREET, MELROSE, MA 02176 662.5863 PROPOSAL UBMITT T /f 7 c. y %v A /� / v 2,4.s'' ADDRESS 11 VPHONE 3� �� � q -7O - 0 S DATE OF LANS bs- JOB A19FIRUMA-TORA JOBPHONE We hereby submit specifications and estimates, subject to all Items and conditions as sat forth below: WKJ7 c� F ems, `( #t yrOnOat hereby to furnish material and labor -complete In accordance with above specifications, for the sum of: dollars (11 Not- This proposal may be wlthdo-wo by us It not accepted within Authorhed days. Blpnatu > ACCt11WO: The above prices. specifications and conditions are satlefac orr and are hereby accepted. You an stdhoftw to do IM work as specified. Psymem will be meat as oulllned above. Date r I. i 6d . A 1 A . 1 P446. 1'7- 0.r— \ \ t xx Y REMODELINGNEWME ASSOCIATES General Contractors 35 PINE STREET, MELROSE, MA 02176 662-5863 PROPOSAL SUBMITTED T OK DA ADDRESS c3,5 7 PHONE E 0 PLANS =F— JOB .. TIE JOBPHONE We hereby submIt specifications mW solmates, subject to all Ilerne s"d conditions as Got forth below: Ian. / � r i JIF / /112111SI S i 1A. 1 Acct ttb: The above Prices. specifications and conditions we satisfactory and am hereby accepted. You are authorized to do the work as specified. Payment will be made as oulfined above. Dal* // Board of dildi ft RegulationsamrStandairds NOMI? iM ROV-EMENT CONTRACTOR ? `• : Registl• 107226 j. p�cat%n X13012006: tJ�BAa. NEW ENGLAND: OM A M 9LINU� f 35 Pine Street �` i�G-.*✓ µ-: `{� Iuleirose; tlA 1)2176' "' ~ Administrator_ _ • L7k ✓BQARD OF BUILDING REGULATIONSLicense: CONSTRUCTION SUrr:RVISOIYNumbs CS 012285 ; Birthdaie>, 08i08Y1946 F xp� 1--i 2007 Tr.:no: 15927 t i ! Re Crit 100 KENNETH M_ 35 PINE Sl MELROSE, MA 02176 .�-' _ Commissioner NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit at: is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11,S150A. Also, note Permits are required under Fire Prevention laws Chapter 148 Section 1 OA. The debris will be disposed of in: Fire Department Sign off: Dumpster Permit MIV S Ai res 7 - (Location of Facility) Signature of Permit Applicant Date m m m m m N m U y COD d C .0 d 'fl O n Z y CL '0. � O C =• CO), n� O d o p CD CD o Q d CD CCD o CD C CD co) G• CD =C y = I co CD S v CO) O 'OCD Z O CCD C CD C CCP C? C d S -� y O Q ti :1 CD y oMac o n mQ d� "1 m co CD CL o wed y o OH O N o �m m Z > >mo O0 o y. CAo . ►-d ► � Cri a aomi.% 4 S n,an""',�: O CD C y C/) y) // C�. & n s, m h O N d� Q C OD d C ^� C/) aco �� 1i1 CA �7 A AE VJ H N� CD N �♦ D Z O ch 'a o zEr CD CAg O - o o ? m : r H W o � o N Crorii cC�,� �A c c Cl) "d Q0p T 5 0 7' r �' m poi T ro C) M ni n o O.. 0. O �.�.I W A � A O O Location ���`� CAA) /&SJ/C/ No. "7 Date c� TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ 3349 Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $ 3 3 S, V ' Building Inspector q nG O� 3 309/99 12:23 338.00 PAI" 1 Div. Public Works Location—,3,5-'7 CA1QJ/1IS41Ic No.! 0 7 Date 12987 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $ 3 3 ?e Building Inspector Div. 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O .a COO) C O V O V1 rwmr� OW19MER— __M96' Pro -Care Inc. 3 North Maple Street Wobum Ma 01801 Fax Date: 2-1 Z_;�5 Number of Pages: - Phone, 731-933-7400 Fax: 731-933-1222 'role "ONI ANV3 Olid dss:zl 66_9Z_qUj Remarks: g2 0 I INA 12� 21fl- 7_� If this fax transmission is incomplete or the clarity is unacceptable, Please call (781) 933-7400 or (800) 660-1973 'role "ONI ANV3 Olid dss:zl 66_9Z_qUj I Sent By:*11AR80R MORTGAGE SOLuTIONg INC.; 7111 8rase. tJ9 43 8861; F�D•2S•98 14.13; Page 212 MORTGAGE INSPECTION PLAN NORTHERN ASSOCIATES, INC. 942 N,MrN $ZAWrr AAVOVER PU 01810 ra, (97B/ 474-4410 FAX.(97gj 474_506i T:4000 KONM R.s PAWLA J.CCua+XLY "o r AiC/. 4098 / 2:1 AM77at M7 r.f8r.—Ve +4040 PLAN OW. PLI$IIiQ Y. t STAR l kWM AAcW1¢A A14 9GLE` I • t0 . 10AFL" M.28.1998 R 98/03169 o�+rrFra� ra i F -M, V k# .NYtN tI.MT.T.r wa n.M.M ' n.. N .. lt1iM •••. M • lt.M I Tt..tTtT I/r T.rw/. rr f.f I.as.s/M. P�.[f 1TTMs tr. ITTtrIM[.rT. 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TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING This certifies has permission to perform_,.'.'.°-,.--. ...................... wiring in the building of ............................................................................ at ....... North Andover, Mass. .............. ......................... Fee !.�.�.. ... . ...... Lic. No. .. ............. ELECTRICAL INSPECTOR 04/0/99 12.51 90.00 WHITE: Applicant CANARY: Building Dept. PPP. Treasurer COMM0Aff 4LTHOFM1MCHUS�'T7S office Use only DEPARTAIDVIOFPUBLICSAFETY Permit No. ,! j 1-7 o BOARD 0FF&EPREVEM70NREGUT4TI0M-V701R 12 -UD Gtr mit% Occupancy &Fees Checked APPLICATION FOR PERAff TO PERFORMELE=CAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 3,,�2� (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date (,/ (�(� Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street &Number) 3� I 0Au j -<:f'r-1 C R vA j Owner r Tenant /<-F AJ ONam. A/LeL\ Owner's Address S,4 M F Is this permit in conjunction with a building permit: Yes, No a (Check Appropriate Box) Purpose of Building �j�j�L� �if��/Y16Lj/ Utility Authorization No. Existing Service c>?00 Amps/30 Zl/OVolts Overhead F-1 Underground ] No. of Meters jn!NL� New Service Amps / Volts Overhead r-7 Underground r-7No. of Meters �-- Nun-,ber of Feeders and Ampacity Ioc. tion and Nature of Proposed Electrical Work --t-- - - U No. of Lighting OutletsNo. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above Below Generators KVA 16 and 0 ground No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Ranges No. of Air Cond. Total Tons No. of Detection and No. of Disposals No. of Heat Total Total Pumps Tons KW Itutiating Devices No. of Sounding Devices No. of Dishwashers Space Area Heating KW No. of Self Contained t Detection/Sounding Devices Locala Municipal Other No. of Dryers Heating Devices KW Connections loo. of Water Heaters KW No. of No. of A signs Badasis No. Hydro Massage Tubs / No. of Motors Total HP Al •� '•✓' 1 J•"•{• �:i'- • :. mill. • .:J I L =wNa /3V9/ -A 7-- Lisee sig>ue -— Liar1seNo ,�^ Business Tea. Na %J"/- 72 g^/93 COX RQQd MAIL OWNER'S INSURANCEWAIVER, ;IamawaetAfie LcmSrdoes nothavetheil rat aMM@2rasSILkSarXWe4 vala>tastt byM Cxroallaws and that mysigrtatseatthis petmitappfira mwaiv!;mumsm#anenf. (Please check one) Owner a Agent Telephone No. PERMIT FEE S r! MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO CASFITT (Print or Type) c NORTH ANDOVER Mass. Date 1huilding Location -� ZZ Permit # /Yiy .� Owners Name !V/15e21�t, / •S • New ;2�- Renovation 0 Replacement Plans Submitted D FIXTUP=Is (Print or Type) Check one: Certificate Installing Company Name��-yl��•C cG C)6jjl Cb Corp. Addressf SCf lit7/�e�S% i We��7o 44 Partner. Firm/ Co. Business Telephone: Name of Licensed Plumber or Gas Fitter Lf2e e�f Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity = Bond Insurance Waiver: 1, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance coverages. ignature of owneriagent of property Owner L1 Agent 0 I hereby certify that all of the dcuils and information 1 have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbirir .writ and (nstAilations performed under Permit issued for this application with be in compliance with ail peztineat provisions of the Massachusetts Stale Gar Code and Chapter 142 of the General Laws. SY TYPE LICENSE: lee Plumber Title Gasfitter Sign ure of Licensed Plum e,��G f- t -.er City/Town: Master l Journeyman , APPROVE]--) (OFFICE use ONLY) License ',- moer to O = to = F�- W U1 01 O U m t- `= to cc W d W W F..0 0- tt W 4 V N 0 W C3W Z V W � W 07 W 4 Q 10 G W = W O W }. 07 Z I� Q 2 +'• W tC W Q 4" O> W tt W h- V C7 tt 2 d W C < cc F' 4 }- W m = O O 0- Z Q> > W 0 G< C O O W— > O W t- o x o O U. Sva—fMMT. BASEMENT IST FLOOR i 2MD FLOOR 3RD FLOOR ( I 4TH FLOOR 5TH FLOOR ( I 6TH FLOOR I TTH FLOOR I 8TH FLOOR (Print or Type) Check one: Certificate Installing Company Name��-yl��•C cG C)6jjl Cb Corp. Addressf SCf lit7/�e�S% i We��7o 44 Partner. Firm/ Co. Business Telephone: Name of Licensed Plumber or Gas Fitter Lf2e e�f Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity = Bond Insurance Waiver: 1, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance coverages. ignature of owneriagent of property Owner L1 Agent 0 I hereby certify that all of the dcuils and information 1 have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbirir .writ and (nstAilations performed under Permit issued for this application with be in compliance with ail peztineat provisions of the Massachusetts Stale Gar Code and Chapter 142 of the General Laws. SY TYPE LICENSE: lee Plumber Title Gasfitter Sign ure of Licensed Plum e,��G f- t -.er City/Town: Master l Journeyman , APPROVE]--) (OFFICE use ONLY) License ',- moer Date ...... ` .... .... . NORTH TOWN OF NORTH ANDOVER pf 11.ao ,6'6 PERMIT FOR GAS INSTALLATION F . �f This certifies that .. i 'rt.�I �:........ ; ................. has permission for gas installation`.....�....:� �.............. in the buildings of !r / . cr..,: t' ................ . at ... ?� 1.. �... .(� r <. �, .a; f {�. /,, , North Andover, Mass. Fee.. . ��. Lic. No.f 7 t r) 7. . 02/231i } Gr.O15. 00 Pp1l1 GAS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File '- 3974 � TO TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING SAC14us This certifies that ...... ............. . has permission to perform.................. . plumbing to the buildings of . ........... at. `3� 7 f �_- *°. r— ; .. , N h Andover, 'Mass. Lic. PLUMBING INSPECTOR ((qAt Q9 c .ttn SAID WHITE: Applicant D39riggeY. wilding Dept. PINK: Treasurer (Type or Print) NORTH ANDOVER ,Mass. V. `. Oaw ' ' Building Location ,R..5 `7 C A k.),t1L��S-n c•i c -Rb, _ . Permit Owners Name New Renovation Replacement Plans S bmitted Q y j' FIXTURE • ' z z z a, x . < N W J >• U az '— W W w Y z orf % J 4 I ccz d h N ? O 1 O _ � Q 1116� Q • 0 W W Qf h A W Z pf 1— U . W Of Y < 93lL z z ~ K .,•l V Z OCC � W 4 It w Q W z Q 4 of c = < aC 0. { aC. J W W 41:Q ~ ►- > 1- ° a zT to 1. Y = o. O O O to 2= _ w W GL o X v WrX Z w N SUB -SBS MT. BASEMENT IST FLOOR 2ND FLOOR .3RD FLOOR ATH FLOOR STH FLOOR 6TH FLOOR 7TR FLOOR 8TH FLOOR i (Print or Type): Check t: Certificate Installing Company Name > upj ,PeAry L-6, 41 ti�C•G, Corp. Address'ZFAQ RLLC—A3 CT Partner. _S rbit *gv/, j" r.» q . 4dt 4Firml Co. Business Telephone(�17)� Name of Licensed Plumber: 1ligmec(*c-) l=1• bASt Liza _ Insurance Coverage: Indicate the type -of insurance coverage by checking the appropriate box: Liability insurance policy Ocher type of indemnity Bond ❑ r U Insurance Waiver: 1, the undersigned, have been made aware -that the licensee of i this application does not have any one of the above three insurance claveragese Signature of ownerlagent of property Owner Agents,. I beabr ccttify Wat all of Uw dclaila and infornulion 1 142.c wbenifIcd lot cnlctcd) in aMr.c arp4kz iiow ate Iter ffa:: aystt to Uta btfl r r1 �. I AQWkdge and "all plualbint walk and inllallapnns ircr(no mcd undcr FcrmiI Ittucd (of fhit applic 604 wiU be in CGUMIUaam Vkh ay PgfbKK PW • eW"& of "M+uxbua Us Statc Plumbiag Codc and Cluptct 142 of flit Ccnu al UwL By Title City/Town: ,ADDQ0VFr) IoFFicF USE ONLY1 Signature of Licensed Plummer Tvpe of Plumbing License License Number Mast4r ❑ Journeyu" .t Location / No. Date �ORT� TOWN OF NORTH ANDOVER O Certificate Occupancy of $ Mus <�' Building/Frame Permit Fee $ Z �' U Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # / Y 17669 Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAI5 RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING . ,�/� BUILDING PERMIT NUMI3ER:G DATE ISSUED;... C� O SIGNATURE: Ty—�� Building Commissioner/Inspector of Buildings Date ?� 6 SECTION 1- SITE INFORMATION 1.1 tProperty Address: 1.2 Assessors Map and Parcel Number: 5- C4�4<< r ,-k fL Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT iS OriCDistrict: Yes No 2.1 Owner of Record Kee C�1��,�Iy JI -7 Name (Print) Address for Service: ,w< co-l""oA-- 9?,P-6 9/- 5175 Signature Telephone t 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor Not Applicable ❑ Licensell Co`nst�ruction{�Su�pervisor.]�.��� 0 l 3 Li cense Number Addr s , 2� 7 b''�S—i2 � Expiration Date Sig,n4tu,rA N Telephone 3.2 Registered Home Impprovement Contractor Not Applicable ❑ C�%opuny Name �Z9 e G 5I"U�nal Registration Number Address p!//-1115 -2x-' 5 6- Expiration Date Si nature Telephone Ma M X ic Z O O z M 90 O M ro z 0 SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 6 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) )< Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: C k) O SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant USEONLY ` 1. Building (a) Building Permit Fee Multiplier .:..:..... 2 Electrical (b) Estimated Total Cost of Construction 3 PlumbinE Building Permit fee (a) X (b) /J � 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 2 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date AGENT DECLARATION SECTION 7b// ,OWNER/AUTHORIZED ,as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief / Print Name ature of Own er/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIIv1BERS 1 2 ND3 SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIlVINEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE Ae Commonwealth of Massachusetts Department ofhtdustrial.4ccidents Office of Investigations 600 Washingrorr Sn•eet Boston <VA 02111 `•Vorhers` COnloensatlon Insurance Propem L)wner `Fame: yob Location: U i am a nomeo"ner performing ail vorx myself. I am a soie proprietor and have no one woricirig in anv canncity am an emoiover nroviaing worxeis' comnensauon for my em lovees woritirto P on this fob. Company Name: T 'llf�c�"U-S CZKGt 1Jdai�s :address: � j SON DZ (Z_ , City:--C1Ulo-W [1 M ,,i1� p j t3 l O�Z Phone-- Phone= $0 Q - $1 / _ (7,7/— `nsurancc Co -10 �.r-i- r Policv= OaWBXLz.44V tt ¢£1:a FL2£Loli ti tt f3 stere sit.,:. ................:.... olicy Faiiure ,o secure covemee as required un;.:.:.;:;.;;;::;.;::>::;:;:;:s>:>.<;::;: el der section 25A of �IGL 152 can lead to the imposition of ctiminai penalties of a fine un to 51.500.00 and or one years nonsonment as well as civil penalties in the form of a STOP WORK ORDER and a tine of 5100.00 a day against me. [ understand that a cony of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. [ do hereby cer•tiry cinder the pains and penaities of pern iury that the information provided above is true and coed. Signature _ ��- _ Sc-a� ff cisfP — Official use only. Do not xTite m this area. to be compieted by city or town official City or Town: Permit/license i# Checx - :rnmeciinre response :s reouired Contact person: Phone ff: 800- 866-91896 C Building Department C Licensing Board C Selectmen's Office C Health Department C Other 0�,Xie Board of Building Regula ions and Standards One Ashburton Place - Room 1301 Boston. Massachusetts 02108 Home Improvement Contractor Registration Reqistration: 129774 Type: Supplement Card Expiration: 11/2/2005 PELLA WINDOWS AND DOORS SCOTT HOUSE 45 FONDI RD. HAVERHILL, MA 01832 DPS-CA1 G 50M -04/04-G1012166 ,a��e c.^anvnza�zurP.a`� c`�.lCauacfLuae�a --_ _ Board of Building Regulations and Standards - —�' — HOME IMPROVEMENT CONTRACTOR -�� Registration: 129774 Expiration: 11/2/2005 Type: Supplement Card PELLA WINDOWS AND DOORS SCOTT HOUSE 45 FONDI RD. HAVERHILL, MA 01832 Update Address and return card. Mark reason for change. Address Renewal — Employment — Lost Card License or registration valid for individul use only before the expiration date. If found return to: Board of Building Regulations and Standards One Ashburton Place Rm 1301 Boston, Ma. 02108 .administrator Not va id without signature ✓ize �oanvnzonuie�i a� . G BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 081843 Birthdate: 02/06/1966 Expires: 02/06/2006 Tr. no: 81843 Restricted: 00 STEPHEN T DICKINSON 17 BURNSIDE LANE MERRIMAC, MA 01860 Administrator North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, S 150 A. The debris will be disposed of in: (Location of Facility) Signature of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector PELLA IS NOT RESPONSIBLE FOR ANY EXISTING SECURITY SYSTEMS. SALESMAN HAS NO AUTHORIZATION TO CHANGE ANY ITEMS OR MAK PLEASE REMOVE ALL SHADES,VERTICALS, BLINDS, CURTAINS, DRAPES ANY REPRESENTATIONS OTHER THAN CONTAINED IN THIS AGREEMEN OR WINDOW MOUNTED AIR CONDITIONERS, PRIORTOTHE INSTALLATION AND "OWNER" REPRESENTS THAT NONE HAVE BEEN MADE TO O OFYOUR NEW WINDOWS. INSTALLERS ARE NOT RESPONSIBLE FORTHE RELIED UPON BY "OWNER". YOU ARE ENTITLED TO A COMPLETEL REMOVAL OR INSTALLATION OF THESE TYPES OF ITEMS. FILLED IN DUPLICATE OF THIS AGREEMENT. CONDENSATION INSIDE THE HOUSE DOES NOT INDICATE A CONTRACT SUBJECTTO FINAL INSPECTION BY PELLA CONSTRUCTIO WARRANTY PROBLEM. DEPARTMENT. TERMS AND CONDITIONS THAT GOVERN THIS CONTRACT ARE PRINTED ON THE REVERSE SIDE. This contract Is a legal document. Your Pella proftocts will be specially made-to-order for you. UNDER NO CIRCUMSTANCES WILL REVISIONS O �./ 4A• Date - Customer Signature< Date: ?/"M/� 01 JF White - Original Yellow - Customer Pink - Store << e C)LA C , �W\at Bows VDOI1-cCi " HIC Registration #129774 Federal ID #04-3277886 Pella Windows & Door., Pella Windows & Doors of Boston 45 Fondi Road ® "Viewed to be the Best" Haverhill, MA 01832 PH: (800) 866-9886 Service: Ext. 124 Fax: (978) 373-7274 WINDOW CONTRACT Sales: (866) Pella06 Sold To: �0 - Date: Address: �� `��� S jz'—' 0� Phone (Home) City:—/%/V&-TV 47-" � State:.L4 Zip: O $1K- Phone (Work) ) '61f? Job site Address (If different): Phone (Cell) Approx. Start Date: Approx. Completion Date: Pella Boston Will Furnish and Install: YE NO PLEASE READ CAREFULLY: ONLY THE ITEMS CHECKED YES ARE INCLUDED 1. ❑ Remove Windows from the opening where the now exist on: d # Openings # New Window Units 2.FIRST LEVEL: _ 3. ❑ SECOND'LEVEL: # Openings # New Window Units 4. ❑ THIRD LEVEL: # Openings # New Window Units 5. ❑ BASEMENT: # Openings # New Window Units 6. ❑ OTHER: # Openings # New Window Units -i r1 21. -25 13 U/.n . I W# .� Roof on Bay/Bow to be: 13 None (Within 18" of Soffit) Asphalt ❑ Cedar 22. ❑ Clean up and vacuum nightly and remove all debris at completion of job site 23. ❑ Remove and Dispose of existing Windows and/or Storm Doors 24. ❑ All workman's compensation and liability insurance maintained 25. ❑ Warranty mailed to customer up q� ompletion when full payment is received � ib AV1V*'y4�w 3-'13 .. (off 1 26. 27. 13 13 Total Project Amount $ 1 _'1-1 Financed If Yes: Amount Finan ed $ a 1D (Reference # °Zbpo i ��000 - 011 ' I �) 28. 29. 13 13 Deposit Received $ 2 Balance on Substantial Completion $ (. ` �— (Payment is payable to installer at completion of job) 30. ❑ Additional Comments: �fVYVI,If'�tfl-�'� PELLA IS NOT RESPONSIBLE FOR ANY EXISTING SECURITY SYSTEMS. SALESMAN HAS NO AUTHORIZATION TO CHANGE ANY ITEMS OR MAK PLEASE REMOVE ALL SHADES,VERTICALS, BLINDS, CURTAINS, DRAPES ANY REPRESENTATIONS OTHER THAN CONTAINED IN THIS AGREEMEN OR WINDOW MOUNTED AIR CONDITIONERS, PRIORTOTHE INSTALLATION AND "OWNER" REPRESENTS THAT NONE HAVE BEEN MADE TO O OFYOUR NEW WINDOWS. INSTALLERS ARE NOT RESPONSIBLE FORTHE RELIED UPON BY "OWNER". YOU ARE ENTITLED TO A COMPLETEL REMOVAL OR INSTALLATION OF THESE TYPES OF ITEMS. FILLED IN DUPLICATE OF THIS AGREEMENT. CONDENSATION INSIDE THE HOUSE DOES NOT INDICATE A CONTRACT SUBJECTTO FINAL INSPECTION BY PELLA CONSTRUCTIO WARRANTY PROBLEM. DEPARTMENT. TERMS AND CONDITIONS THAT GOVERN THIS CONTRACT ARE PRINTED ON THE REVERSE SIDE. This contract Is a legal document. Your Pella proftocts will be specially made-to-order for you. UNDER NO CIRCUMSTANCES WILL REVISIONS O �./ 4A• Date - Customer Signature< Date: ?/"M/� 01 JF White - Original Yellow - Customer Pink - Store CA m m x m y m C2 CA C � — d CODCD C..� SZ Z y d.O n, logoC CL y aCc -0o a) Co o p o.� o c� =r %4C CD CD o CD C O co) CD =0 y �C I C2 Cos O .p CD O CD CD IC W-0"0 — _ s =_ ce to a. O s • y SO m CL aC m n C3 cm CL a M ?lo w 0 �1 stm LA. T ? CL CL m 0 Fn - go N � b_ mr 0 co �o o d o z.. es n o d+ CD ��CD o 3w 0 ML m O .. Cn m CD Cn • CO -3= C CD nM st CA \•, O m y O z H ad :; �i Cn a ♦� ,ncooa & C Cn y vi ,� O Z E; m rn � m w �z Amo �Cn 0 •e : = 2 d =r o : w I.0 0 ons C A o o, IA O m �q ly� �, co a�- o c° o yg D �Q y 0